Lusail Development Project

HSSELQ Department

HAZARDOUS (MATERIALS or EQUIPMENT) ENTRY / EXIT FORM

DATE: / / / 2015
Must be completed by Applicant
Project Name/ Location

Company Name

Applicant name

Project Contract End Date

Purpose of Entry / Exit

Duration (in Days)

Requested For Entry / Exit

Main Contractor Details
Company Stamp
Authorized Signatory Name

Position

Signature
Vehicle Information
Vehicle Plate Number Vehicle Type

LIST OF HAZARDOUS MATERIALS PRESENT ( )

PRESENT NOT PRESENT REMOVAL DETAILS (SPECIFY QUANTITY)
ASBESTOS MATERIALS
UNDERGROUND STORAGE TANKS
ABANDONED CHEMICALS
IGNITABLE
CORROSIVES
RADIOACTIVE
TOXICITY CHARACTERISTIC (TC)
DISCARDED CHEMICAL PRODUCTS
MEDICAL WASTES
WASTE OIL
PCBS
WASTE WATER (e.g.; SEWAGE)
OTHERS
WASTE FROM NON SPECIFIC SOURCE OR
SPECIFIC SOURCES EXCEPT WASTE OIL
Approval from LREDC HSSELQ Department
Logistics Security HSSELQ Department Stamp
Name Mhd W Ayroud Zaal Al Naemi

Signature

Date

Sr. Logistics & Security Manager Sr. HSE & Fire Manager HSSELQ Director

Name Yousuf Al Mutawa Michael Ford Waleed Al Khal Fahkroo

Signature

Date
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 Lusail Development Project
HSSELQ Department

HAZARDOUS (MATERIALS or EQUIPMENT) ENTRY / EXIT FORM

DECLARATION BY MAIN CONTRACTOR (AUTHORIZED SIGNATORY)

I, , certify that the information provided on this form is accurate with

the proposed Hazardous Materials indicated in overleaf, and that all hazardous materials in violation if the applicable
regulations should be removed from Lusail.

DOCUMENTS REQUIRED FOR PERMITTING HAZARDOUS MATERIALS ENTERING LUSAIL

1. A Hazardous Materials risk assessment completed by a qualified person, MUST be submitted with this form.
2. All hazardous materials identified above and/or in the attached assessment shall be handled and are found during
the demolition process, disposed of in accordance with all applicable rules and regulations.
In the event that hazardous materials work must cease until they are removed.
3. Documentation from the assessment, removal and disposal of hazardous materials (i.e. receipts, inspection reports,
clearance letters, sampling reports, waste manifests, etc.) must be attached.
4. Safety representative from relevant Contractor / Developer must escort the Vehicle carrying the Hazardous Materials
5. All supporting document must be attached with the application form. i.e. license & registration card by the appropriate
authority, operator training certificate etc.

Signature / Date Mobile Phone Number email Id

Examples;
Asbestos: Possible materials include siding, pipe insulation, pipe tape, ceiling tile, drywall joint compound,
vinyl sheet flooring, vinyl tiles, lag pipe, insulation asbestos board and linoleum.
Underground Tanks: Fuel tanks for heating/cooling systems. Look for fill pipes, vent pipes. Should a tank be found
during excavation, then work must cease until the tank and its contents have been removed.
PCBs: Possible materials include fluorescent lighting ballasts, power transformers, generators and
other power supply and management equipment.
Abandoned Chemicals: Possible materials include paint, solvents, oils, cleaning products, flammable and combustible
substances like gasoline, pesticides, herbicides, and medications.
Others: Other hazardous materials may include Freon from cooling equipment and mercury switches.

Note:
1. An approved application copy must be filed at LREDC Safety and Security Section
2. This pass should be provided at the Entry & Exit Gate
3. All relevant fields to be filled and approved from the authorized Developer/ Contractor.
4. Strict measures shall be taken against traffic/logistics offences and other breaches.
5. Requestor must follow signature sequence
6. Request approval will take minimum 4 working days for complete approval process.

Lusail Development Logistics Services

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